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Description : Check out this medical presentation on Diastolic Heart Failure, which is titled "Dyspnea", to know about dyspnea, an unpleasant or uncomfortable respiratory sensations.

Tags : Diastolic Heart Failure, Dyspnea

Published on : Jul 01, 2021 | Views : 3870 | Downloads : 12

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Slide 1-

Dyspnea Chang Shim, MD Pulmonary Division Jacobi Medical Center
Slide 2-

Dyspnea Definition: Unpleasant or uncomfortable respiratory sensations A subjective experience of breathing discomfort. The experience derives from interactions among multiple physiological, psychological, social and environmental factors.
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Dyspnea Common complaint among the general population. 6%-27% of different gender and age strata (37-70 yrs) in the Framingham Study 2.7% of the emergency room visits Most common: asthma, myocardial dysfunction, COPD, interstitial lung disease
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American Thoracic Society Shortness of Breath Scale Grade Degree Description 0 none No trouble walking up a slight hill 1 mild SOB hurrying on the level or walking up a slight hill moderate Walks slower than the peers; has to stop for SOB walking at own pace severe Stops for breath after walking about 100 yards or after a few minutes 4 very severe Too breathless to leave the house or breathless on dressing or undressing
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Dyspnea: Direct Measurement Visual Analog Scale Not breathless---------------------------------------------Extremely breathless Modified Borg Scale 0 none 0.5 very, very slight very slight slight Moderate somewhat severe Severe very severe very, very severe 10 maximal
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Physiologic Categories of Diseases Causing Dyspnea-1 Mechanical interference with ventilation Obstruction of airflow Asthma, emphysema Endobronchial tumor Tracheal stenosis Stiff lungs Interstitial fibrosis LV failure Lymphangitic carcinoma Resistance to expansion of the chest wall or diaphragm Obesity Pleural thickening Kyphoscoliosis Abdominal mass, ascites, pregnancy
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Physiologic Categories -2 Weakness of the respiratory pump Absolute Prior polio Neuromuscular disease- Guillain-Barre syndrome Myasthenia gravis, muscular dystrophy, SLE, Hyperthyroidism, hypothyroidism, multiorgan dysf Relative Pleural effusion Pneumothorax Hyperinflation (emphysema)
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Physiologic Categories -3 Increased respiratory drive Hypoxia Metabolic acidosis Stimulation of intrapulmonary receptors- infiltrative lung disease, pulmonary hypertension, pulmonary edema
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Physiologic Categories-4 Wasted ventilation Capillary destruction: emphysema, interstitial lung disease Large vessel obstruction: pulmonary embolism, pulmonary vasculitis Psychological dysfunction Anxiety-panic state, depression, litigation
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Mechanisms of Dyspnea Originates with the activation of sensory systems involved with respiration. Relayed to the higher brain centers for processing of respiratory-related signals and cognitive and behavioral influences shape the ultimate sensation.
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Evaluation of the Patient with Dyspnea History and physical examination: characteristics of symptoms, quality, intensity, duration, distress. Specific activities associated with dyspnea Quantify intensity of dyspnea Effect on life quality Cardiovascular vs pulmonary dyspnea, or both
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Special Studies-1 Pulmonary function studies Lung volumes and flow rates Diffusing capacity (DLCO) Arterial blood gases Cardiopulmonary exercise testing Bronchial challenge Maximal inspiratory pressure
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Special Studies-2 Imaging studies Ventilation-perfusion lung scan Chest CT, HRCT (high resolution CT) Gallium scanning Diaphragmatic fluoroscopy
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Special Studies-3 Cardiac evaluation Echocardiogram-for ventricular size and function, regional wall motion abnormalities Dobutamine stress echocardiography-regional wall motion abnormalities. Thallium perfusion scan Holter monitor Cardiac catheterization/coronary angiography Plasma BNP or N-terminal pro-BNP most HF patients >400 pg/ml; normals 10 pg
Slide 16-

Special Studies-4 Sleep studies Esophageal pH monitor ENT examination Psychological assessment
Slide 17-

Treatment of Dyspnea Altered Central Perception Cognitive-behavioral strategies Perception of dyspnea results in part from the effects of cognitive, emotional, and behavioral factors on the conscious awareness of the demand to breathe and the affective response to the symptom. Education about the disease process Teaching of the coping skills, for example, relaxation, distraction, reassurance
Slide 18-

Asthma Reverse airflow obstruction Bronchodilators, anti-inflammatory agents Relieve chest tightness Same as above Control cough Same, + cough meds & local anesthetics Relieve anxiety Anxiolytics: usually contraindicated Rare exceptions: benzodiazepines, opiates
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Reduce Resistive Load Reverse bronchoconstriction. Decrease airway inflammation and edema Pharmacological therapy Inhaled beta2-agonists, short and long-act Inhaled anticholinergics Theophylline probably related to deceased operational lung volumes.
Slide 20-

COPD Reverse airflow obstruction: anti-cholinergics (short and long acting), corticosteroids, long acting beta agonists, theophylline Reverse hyperinflation/air trapping Inhalation meds, Expiratory maneuvers, LVRD Exercise rehabilitation
Slide 21-

COPD LVRS (lung volume reduction surgery):NETT Oxygen NIPPV for acute exacerbation Reduce ventilatory requirements: metabolism, V/Q, exercise rehab. Central drive: depressants: benzodiazepines, opiates
Slide 22-

Treatment of Dyspnea Reduce ventilatory demand Increased VE or VE/MVC (maximal ventilatory capacity) correlates with exertional dyspnea. Reduce CO2 output, VD/VT (physiologic dead space), arterial hypoxemia, metabolic acidosis. Hyperventilation itself causes dyspnea.
Slide 23-

Reducing Metabolic Load Exercise training Improves aerobic capacity Reduces rate of rise of lactate levels with exercise Decreases exertional dyspnea Improves exercise tolerance Reduces VE per work rate primarily by decreasing breathing frequency. VCO2 and VO2 reduced at a given work rate=improved efficiency.
Slide 24-

Reducing Metabolic Load Supplemental oxygen during exercise Patients with chronic lung disease have reductions in blood lactate and VE
Slide 25-

Decreasing Central Drive Inhaled pharmacologic therapy Lidocaine may alter afferent information from the pulmonary receptors: Asthma Low dose opiates via nebulizers ? Fans: mechanoreceptors on the face or decrease in temperature of facial skin Improve efficiency of CO2 elimination VD/VT is increased. Slow deep breath Altered breathing pattern: slow deep breathing, diaphragmatic breathing, pursed lip breathing
Slide 26-

Decreasing Central Drive Oxygen Therapy Depress hypoxic drive from the peripheral chemoreceptors in the carotid body. Oxygen may blunt pulmonary artery pressure rise with exercise. Oxygen may improve ventilatory muscle function. Airflow over the face or nasal mucosa may ameliorate dyspnea.
Slide 27-

Decreasing Central Drive Oxygen Therapy As an adjunct to exercise training program. Prevents skeletal muscle deconditioning by increasing ADL. Criteria: PO2 =<55 mmHg or 56-59 mmHg with polycythemia or cor pulmonale. Flow rate should be adjusted to correct hypoxemia. Delivery by nasal canula, face mask, transtracheal catheter
Slide 28-

Decreasing Central Drive Pharmacologic therapy Opiates Respiratory depressants reduce the central processing of neural signals. Reduce VE & VO2 at rest and exercise. Endogenous opioids modulate dyspnea in acute bronchoconstriction. Opiates may alleviate dyspnea by blunting perception. Side effects: hypercapnea, altered mental status, constipation, nausea, vomiting, drowsiness Inhaled opiates are not effective.
Slide 29-

Decreasing Central Drive Anxiolytics May relieve dyspnea by depressing hypoxic or hypercapnic ventilatory responses. May alter emotional responses to dyspnea. Benzodiazepines failed to demonstrate consistent improvement in dyspnea. Poorly tolerated. May benefit individuals with respiratory panic attacks, but needs close monitoring.
Slide 30-

Reducing Ventilatory Impedance Reduce lung hyperinflation Dynamic hyperinflation during exercise or hyperventilation—auto-PEEP or intrinsic PEEP is important contributor to dyspnea. Surgical volume reduction Unilateral bullectomy, or lung volume reduction surgery (LVRS) benefits by reduction of operating lung volumes. Dyspnea decreased by reduced dynamic hyperinflation, improved chest wall mechanics and increased lung recoil and increased airflow.
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Lung Volume Reduction Surgery in Emphysema
Slide 33-

Lung Volume Reduction Surgery
Slide 34-

Continuous positive airway pressure (CPAP) Low levels of CPAP relieve dyspnea in Acute bronchoconstriction in asthma, Patients weaning from mechanical ventilation, During exercise in advanced COPD. Benefits of CPAP are probably related to reduction in auto PEEP
Slide 35-

Improving Inspiratory Muscle Function Strength and Endurance Respiratory muscle weakness, fatigue and dyspnea Decreased body weight—decreased diaphragm mass, decreased intercostal muscle fiber size Weight loss of >10% of ideal body weight Improvement of respiratory muscle function with enteral or parenteral nutrition Inspiratory muscle training? Positioning: leaning forward position Partial ventilatory support Minimizing the use of steroids
Slide 36-

Obesity Apple shaped, in contrast to pear shaped, is more burdensome to diaphragmatic movement. Central respiratory drive: supernormal Upper airway dimension: crowded, relaxed muscle Airway dimension is related to lung volume. Upright position, unloading of the diaphragm CPAP (continuous positive airway pressure) prevents large airway collapse Bariatric surgery
Slide 37-

Paralysis, Chest wall abnormality Reversible conditions, myasthenia, Guillain Barre: mechanical ventilation until recovery of neuro-muscular function Correct chest wall abnormality if feasible: pleural effusion, pneumothorax, flail chest NIPPV
Slide 38-

Diagnosis of Diaphragmatic Paralysis Unilateral: often asymptomatic VC sitting and supine Sniff test under fluoroscopy Sonography
Slide 39-

Sniff Test Not the cocaine variety Sniff is a potent, brief inspiratory maneuver everyone is familiar with. Monitor diaphragmatic movement (fluoroscopic imaging) from the patient’s side during sniffing. The paralyzed diaphragm moves up paradoxically while the intact diaphragm descends sharply.
Slide 40-

Dyspnea in Diaphragm Paralysis Body position or posture Exercise tolerance Stretch receptors in the muscles and tendons Activities: rest, sleep, exertion
Slide 41-

Diaphragm Pacer
Slide 42-

Hyperventilation Syndrome Anxiety-panic attacks Shortness of breath, tingling in finger tips, circum-oral numbness, dry mouth, globus hystericus, sense of doom. In association with asthma, COPD, vocal cord dysfunction: management problem (beta agonist). Important to dissociate asthma from hyperventilation: PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee. Pharmacologic: narcotics, benzodiazepines Self-corrected once patient lapses into coma
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END
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Dyspnea Assessment Borg scale for severity Sensation: inability to inhale deeply inability to exhale properly Hyperinflation or air trapping in obstructive lung disease Position or posture, helpful, detrimental Bending over vs tripod positions in adults
Slide 49-

Dyspnea in Obesity Position or posture Activity Walking, climbing stairs Bending over Supine position with choking sensation Lateral decubitus with pendulous belly is better tolerated.
Slide 50-

Dyspnea with CHF Receptors for dyspnea in J receptors or airway or stretch receptors in left atrium Small airways dysfunction from peri-bronchial edema. Interstitial vs alveolar space edema Oxygen desaturation
Slide 51-

Decreasing Central Drive Pharmacologic therapy Opiates Respiratory depressants reduce the central processing of neural signals. Reduce VE & VO2 at rest and exercise. Endogenous opioids modulate dyspnea in acute bronchoconstriction. Opiates may alleviate dyspnea by blunting perception. Side effects: hypercapnea, altered mental status, constipation, nausea, vomiting, drowsiness Inhaled opiates are not effective.
Slide 52-

Decreasing Central Drive Anxiolytics May relieve dyspnea by depressing hypoxic or hypercapnic ventilatory responses. May alter emotional responses to dyspnea. Benzodiazepines failed to demonstrate consistent improvement in dyspnea. Poorly tolerated. May benefit some individuals with respiratory panic attacks, but need close monitoring.
Slide 53-

Reducing Ventilatory Impedance Reduce lung hyperinflation Dynamic hyperinflation during exercise or hyperventilation—auto-PEEP or intrinsic PEEP is important contributor to dyspnea. Surgical volume reduction Unilateral bullectomy, or lung volume reduction surgery (LVRS) benefits by reduction of operating lung volumes. Dyspnea decreased by reduced dynamic hyperinflation, improved chest wall mechanics and increased lung recoil and increased airflow.
Slide 54-

Continuous positive airway pressure (CPAP) Low levels of CPAP relieve dyspnea in Acute bronchoconstriction in asthma, Patients weaning from mechanical ventilation, During exercise in advanced COPD. Benefits of CPAP are probably related to reduction in auto PEEP
Slide 55-

Improving Inspiratory Muscle Function Strength and Endurance Respiratory muscle weakness, fatigue and dyspnea Decreased body weight—decreased diaphragm mass, decreased intercostal muscle fiber size Weight loss of >10% of ideal body weight Improvement of respiratory muscle function with enteral or parenteral nutrition Inspiratory muscle training? Positioning: leaning forward position Partial ventilatory support Minimizing the use of steroids
Slide 56-

Obesity Apple shaped, in contrast to pear shaped, is more burdensome to diaphragmatic movement. Central respiratory drive: supernormal Upper airway dimension: crowded, relaxed muscle Airway dimension is related to lung volume. Upright position, unloading of the diaphragm CPAP (continuous positive airway pressure) prevents large airway collapse Bariatric surgery
Slide 57-

Paralysis, Chest wall abnormality Reversible conditions, myasthenia, Guillain Barre: mechanical ventilation until recovery of neuro-muscular function Correct chest wall abnormality if feasible: pleural effusion, pneumothorax, flail chest NIPPV
Slide 58-

Hyperventilation Syndrome Anxiety-panic attack Shortness of breath, tingling in finger tips, circumoral numbess, dry mouth, globus hystericus, sense of doom. In association with asthma, COPD, vocal cord dysfunction: management problem (beta agonist). Important to dissociate asthma from hyperventilation: PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee. Pharmacologic: narcotics, benzodiazepines Self-corrected once patient lapses into coma.
Slide 59-

Dyspnea Assessment Borg scale for severity Sensation: inability to inhale deeply inability to exhale properly Hyperinflation or air trapping in obstructive lung disease Position or posture, helpful, detrimental Bending over vs tripod positions in adults
Slide 60-

Dyspnea in Obesity Position or psture Activity Walking, climbing stairs Bending over Supine position with choking sensation Lateral decubitus with pendulous belly is better tolerated
Slide 61-

Dyspnea with CHF Receptors for dyspnea in J receptors or airway or stretch receptors in left atrium Small airways dysfunction for peri-bronchial edema. Interstitial vs alveolar space Oxygen saturation
Slide 62-

Improving Inspiratory Muscle Function Strength and Endurance Respiratory muscle weakness, fatigue and dyspnea Decreased body weight—decreased diaphragm mass, decreased intercostal muscle fiber size Weight loss of >10% of ideal body weight Improvement of respiratory muscle function with enteral or parenteral nutrition Inspiratory muscle training? Positioning: leaning forward position Partial ventilatory support Minimizing the use of steroids
Slide 63-

Obesity Apple shaped, in contrast to pear shaped, is more burdensome to diaphragmatic movement. Central respiratory drive: supernormal Upper airway dimension: crowded, relaxed muscle Airway dimension is related to lung volume. Upright position, unloading of the diaphragm CPAP (continuous positive airway pressure) prevents large airway collapse Bariatric surgery
Slide 64-

Paralysis, Chest wall abnormality Reversible conditions, myasthenia, Guillain Barre: mechanical ventilation until recovery of neuro-muscular function Correct chest wall abnormality if feasible: pleural effusion, pneumothorax, flail chest NIPPV
Slide 65-

Hyperventilation Syndrome Anxiety-panic attacks Shortness of breath, tingling in finger tips, circumoral numbess, dry mouth, globus hystericus, sense of doom. In association with asthma, COPD, vocal cord dysfunction: management problem (beta agonist). Important to dissociate asthma from hyperventilation: PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee. Pharmacologic: narcotics, benzodiazepines Self-corrected once patient lapses into coma.
Slide 66-

Dyspnea Assessment Borg scale for severity Sensation: inability to inhale deeply inability to exhale properly Hyperinflation or air trapping in obstructive lung disease Position or posture, helpful, detrimental Bending over vs tripod positions in adults
Slide 67-

Dyspnea in Obesity Position or psture Activity Walking, climbing stairs Bending over Supine position with choking sensation Lateral decubitus with pendulous bellybetter tolerated
Slide 68-

Physiologic Categories of Diseases-3 Increased respiratory drive Hypoxia Metabolic acidosis Stimulation of intrapulmonary receptors- infiltrative lung disease, pulmonary hypertension, pulmonary edema
Slide 69-

Physiologic Categories-4 Wasted ventilation Capillary destruction: emphysema, interstitial lung disease Large vessel obstruction: pulmonary embolism, pulmonary vasculitis Psychological dysfunction Anxiety, depression, litigation
Slide 70-

Dyspnea with CHF Receptors for dyspnea in J receptors or airway or stretch receptors in LA Small airways dysfunction for peri-bronchial edema. Interstitial vs alveolar space Oxygen saturation
Slide 71-

Dyspnea with CHF Receptors for dyspnea in J receptors or airway or stretch receptors in LA Small airways dysfunction for peri-bronchial edema. Interstitial vs alveolar space Low pO2, low cardiac output, tissue acidosis, pulmonary interstitial pressure
Slide 72-

Dyspnea and circumstances Effect of Anxiety on respiratory sensation Anxiety provoked from dyspnea Interactions of anxiety and dyspnea Asthma and panic attacks Asthma and vocal cord dysfunction